PROJECT SUMMARY/ABSTRACT The recent HIV outbreak linked to the injection of prescription opioids in Scott County, Indiana highlighted the vulnerability of rural communities to the introduction and rapid transmission of HIV and viral Hepatitis among persons who inject drugs (PWID). In the wake of this epidemic, jurisdictions across the United States have renewed efforts to address the syndemic of opioid injection and HIV infection, including by implementing syringe services programs (SSPs). SSPs are associated with decreases in incidence rates of HIV and viral Hepatitis among PWID. Modeling studies have shown that SSP implementation is cost-effective, resulting in millions in healthcare cost savings from averted HIV infections. Although the public health benefits of SSPs are well documented, most studies that examined their utility were conducted in major urban areas; a scarcity of literature exists regarding rural SSP implementation. This is a critical gap in the literature given that the Centers for Disease Control and Prevention identified 220 predominantly rural counties across 26 states that are vulnerable to an opioid injection-related HIV outbreak. The purpose of this research is to address this gap in our understanding of rural SSPs through the following specific aims: (1) to determine what individual-level (e.g., gender, injection drug of choice) and community-level characteristics (e.g., unemployment and arrest rates) are associated with HIV prevention services utilization (e.g., SSP engagement, HIV testing) among SSP users (n=330) and nonusers (n=330) in two rural Appalachian counties vulnerable to HIV outbreak; (2) to explore barriers and facilitators (e.g., community response, policy environment) of SSP implementation in two rural Appalachian counties vulnerable to HIV outbreak with and without SSPs among 40 stakeholders; (3) to conduct cost analyses of SSP implementation in two rural Appalachian counties vulnerable to HIV outbreak. Aim 1 will allow us to better understand the individual and community characteristics associated with HIV prevention services utilization among rural PWID. These data will inform the development of future interventions that aim to reduce HIV risk behaviors among rural PWID. Through semi-structured key informant interviews (Aim 2), we will be able to compare the barriers and facilitators of SSP implementation in rural counties with and without SSPs. The results of Aim 3 will shed insights on rural SSP implementation costs and how service delivery may be impacted by changes in funding levels. This research project will be embedded in a comprehensive training program consisting of coursework, seminars, guided study, and mentorship by an established team of experts. The training program is designed to further my strengths and to develop new research skills while contributing to our scientific understanding of rural SSPs. The training proposal details a five-year plan of formal and informal instruction in: multilevel modeling, implementation science, and cost analyses. My short-term career goals include: completing coursework in all training areas, disseminating study findings through publications and presentations, engaging in career development activities, and applying for independent R01 funding in the latter years of the award. My long-term career goal is to become an independent investigator in drug dependence and HIV prevention in rural areas.